Obesity in Pregnancy Weighs Heavily on Healthcare Services

Action Points

Explain to interested patients that compared with normal-weight women, obese pregnant women are more likely to require Caesarean delivery, have longer hospital stays, and have other high-risk conditions.

ATLANTA, Ga., April 3 -- Pregnant women who were overweight were more likely to use all levels of healthcare services -- from prenatal testing, to Caesarean section, to phone calls -- than normal-weight women, a study found.

Among pregnant women in a large U.S. group-practice HMO, those who were overweight or obese before pregnancy had higher rates of gestational diabetes, pre-existing diabetes, and hypertensive disorders, Susan Y. Chu, Ph.D., of the CDC here, and colleagues, reported in the April 3 issue of the New England Journal of Medicine.

As a result, the researchers said, these women made greater use of healthcare services, had significantly longer hospital stays, and had higher rates of prenatal testing, outpatient medications, telephone calls, and prenatal visits than did normal-weight women.

Obesity during pregnancy is now a common high-risk obstetrical condition affecting about one woman in five who give birth in the U.S., the researchers said.

To estimate the increased use of healthcare services associated with obesity during pregnancy, the researchers used electronic data systems to identify 13,442 pregnancies that resulted in live births or stillbirths among women 18 or older at the time of conception.

The women were enrolled in Kaiser Permanente Northwest, a large HMO, and were studied from January through December 2004.

The researchers assessed associations between health services and body-mass index (BMI) before pregnancy or in early pregnancy. The primary outcome was the mean length of hospital stay for delivery.

After adjustment for age, race or ethnic group, level of education, and parity, the mean (Â±SE) length of hospital stay for delivery was significantly (P<0.05) greater among women who were overweight (3.7Â±0.1 days), obese (4.0Â±0.1 days), very obese (4.1Â±0.1 days), and extremely obese (4.4Â±0.1 days) than among women with a normal BMI (3.6Â±0.1 days).

A higher-than-normal BMI was associated with significantly more prenatal fetal tests, obstetrical ultrasonograms, medications dispensed from the outpatient pharmacy, telephone calls to the ob-gyn department, and prenatal visits with physicians.

For example, among women with a high-risk condition, the number of obstetrical sonograms was significantly higher for women in the two highest BMI categories. The number of sonograms for high-risk normal women was 6.6 versus 7.1 for obese women, 9.2 for very obese, and 11.0 for extremely obese women.

An above-normal BMI was also associated with significantly fewer prenatal visits with nurse practitioners and physician assistants rather than with physicians. For example, 4.9 visits for a normal BMI versus 4.6 (obese), 4.5 (very obese), and 3.9 (extremely obese).

The difference in prenatal visits to a physician even by women without a high-risk condition, suggests that regardless of risk status, physicians, rather than mid-level providers, are more likely to provide prenatal care for women with a higher BMI, with attendant cost implications, the researchers said.

In addition, the researchers noted, the use of medications and
telephone calls rose with increasing BMI even among women without a high-risk condition. It was not possible, they said, to determine whether these increases represented health-seeking behavior or greater needs related to other, unknown complications related to high BMI.

The study's limitations included the fact that the women were members of an HMO in the Northwest in which a relatively high percentage were white and highly educated, so that the results may not be generalizable, the researchers wrote.

Also, electronic records and birth certificates used in the study may have had coding errors, and because it was not possible to validate reported diagnoses, misclassification of clinical conditions was possible.

According to a recent estimate, the researchers said, about 22% of pregnant women in nine states are obese. This can be extrapolated to indicate that of the four million U.S. births each year, approximately one million involve obese women.

"Thus even a small increase in the cost of heath care associated with obesity will have substantial economic implications," they concluded.

No potential conflict of interest was reported.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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